In vitro evaluation of ICDAS and radiographic examination of occlusal surfaces and their association with treatment decisions

Oper Dent. 2011 Mar-Apr;36(2):133-42. doi: 10.2341/10-006-L.


This in vitro study evaluated the performance of visual (International Caries Detection and Assessment System [ICDAS]) and radiographic (bitewing [BW]) examinations for occlusal caries detection and their associations with treatment decision (TD). Permanent teeth (n=104) with occlusal surfaces varying from sound to cavitated were selected. Sites were identified from 10× occlusal surface photographs. Standardized bitewing (BW) radiographs were taken. Four dentists with at least five years of experience scored all teeth twice (one-week interval) for ICDAS (0–6), BW (0=sound, 1=caries restricted to enamel, 2=caries in outer third dentin, 3=caries in inner third dentin), and TD (0=no treatment, 1=sealant, 2=microabrasion and sealant, 3=round bur sealant, 4a=resin, 4b=amalgam). Histological validation was performed by observation under a light microscope, with lesions classified on a five-point scale. Intraexaminer and interexaminer repeatability were assessed using two-way tables and intraclass correlation coefficients (ICCs). Comparisons between percentage correct, specificity, sensitivity, and area under the receiver-operating characteristic (ROC) curve were performed using bootstrap analyses. ICCs for intraexaminer and interexaminer repeatability indicated good repeatability for each examiner, ranging from 0.78 to 0.88, and among examiners, ranging from 0.74 to 0.81. Correlation between ICDAS and TD was 0.85 and between BW and TD was 0.78. Correlation between the methods and histological scores was moderate (0.63 for ICDAS and 0.61 for BW). The area under the ROC curve was significantly greater for ICDAS than for BW (p<0.0001). ICDAS had significantly lower specificity than BW did (p=0.0269, 79% vs 94%); however, sensitivity was much higher for ICDAS than for BW (p<0.0001, 83% vs 44%). Data from this investigation suggested that the visual examination (ICDAS) showed better performance than radiographic examination for occlusal caries detection. The ICDAS was strongly associated with TD. Although the correlation between the ICDAS and BW was lower, it is still valuable in the clinical decision-making process.

Publication types

  • Evaluation Study

MeSH terms

  • Area Under Curve
  • Bicuspid / diagnostic imaging
  • Bicuspid / pathology
  • Composite Resins / chemistry
  • Decision Making*
  • Dental Amalgam / chemistry
  • Dental Caries / diagnosis*
  • Dental Caries / diagnostic imaging
  • Dental Caries / prevention & control
  • Dental Cavity Preparation / instrumentation
  • Dental Enamel / diagnostic imaging
  • Dental Enamel / pathology
  • Dental Materials / chemistry
  • Dental Restoration, Permanent / methods
  • Dentin / diagnostic imaging
  • Dentin / pathology
  • Enamel Microabrasion
  • Humans
  • Molar / diagnostic imaging
  • Molar / pathology
  • Observer Variation
  • Patient Care Planning*
  • Physical Examination / standards*
  • Pit and Fissure Sealants / therapeutic use
  • ROC Curve
  • Radiography, Bitewing / standards*
  • Sensitivity and Specificity


  • Composite Resins
  • Dental Materials
  • Pit and Fissure Sealants
  • Dental Amalgam